Provider Demographics
NPI:1487879094
Name:CENLA UROLOGY CLINIC LLC
Entity type:Organization
Organization Name:CENLA UROLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:EDENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-442-3384
Mailing Address - Street 1:3311 PRESCOTT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3900
Mailing Address - Country:US
Mailing Address - Phone:318-442-3384
Mailing Address - Fax:318-442-3385
Practice Address - Street 1:3311 PRESCOTT RD STE 100
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3917
Practice Address - Country:US
Practice Address - Phone:318-442-3384
Practice Address - Fax:318-442-3385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL009778208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1792101Medicaid
LA54086B875Medicare ID - Type Unspecified
LAB65692Medicare UPIN
LA55265B875Medicare ID - Type Unspecified
LA1792101Medicaid